Fields marked with an asterisk (*) are required.
To receive your Assisted Living Administrator renewal license, The below items MUST be faxed (334) 801-9579 or emailed by the expiration date of your license.
  • A Copy of NHA license renewal card
  • A Copy of State license of the assisted living facility for which you have administrative responsibility
*License Number:
*Last 4 of SSN:
Version 2.1.5